Clinical Pearls & Morning Reports
Despite efforts to identify patients who are at increased risk for postpartum hemorrhage, this life-threatening complication often occurs in women who have no identifiable risk factors. Read the NEJM Review Article here.
Q: Name the four causes of postpartum hemorrhage.
A: The causes of postpartum hemorrhage can be summarized by the four “T’s”: tone (uterine atony), trauma (lacerations or uterine rupture), tissue (retained placenta or clots), and thrombin (clotting-factor deficiency). The most common cause is uterine atony (accounting for approximately 70% of cases), followed by obstetrical lacerations (approximately 20%), retained placental tissue (approximately 10%), and clotting-factor deficiencies (<1%).
Q: What pharmacologic agent is the mainstay of treatment for postpartum hemorrhage due to uterine atony?
A: Oxytocin (administered intravenously or intramuscularly) is the mainstay of treatment for controlling postpartum hemorrhage due to uterine atony; administration of oxytocin is usually begun simultaneously with uterine massage, if the agent has not already been administered prophylactically. Additional agents (e.g., methylergonovine maleate, a semisynthetic ergot alkaloid) and intramuscular prostaglandins (e.g., carboprost tromethamine, a 15-methyl analogue of prostaglandin F2α) can be used as second-line pharmacotherapy to control postpartum hemorrhage.
A: If pharmacotherapy fails in the management of uterine atony, mechanical methods, including balloon tamponade and uterine compression sutures, can be lifesaving. Balloon tamponade systems, such as the Bakri balloon, first described in 2001, involve instilling fluid (to a maximum volume of approximately 500 ml) into an intrauterine balloon, with removal of the balloon up to 24 hours after insertion; the tamponade effect of the filled balloon is intended to stop or reduce intrauterine bleeding. A 2020 systematic review and meta-analysis concluded that uterine balloon tamponade systems appear to be safe, with a success rate of more than 85% in the management of postpartum hemorrhage. Uterine compression sutures, also known as “brace sutures,” were first described in 1997 by B-Lynch and colleagues and were shown to be highly effective in controlling postpartum hemorrhage. Since 1997, several other compression suture techniques have been described. Several systematic reviews of case series have shown a combined success rate of more than 90% with the use of brace sutures in managing postpartum hemorrhage. Uterine necrosis and intrauterine synechiae are possible complications of uterine compression procedures. The frequency of successful pregnancy after management of postpartum hemorrhage with uterine compression sutures has ranged from 11 to 75%. Uterine and vaginal packing has been used successfully in cases of postpartum hemorrhage, but it is not routinely recommended because of the potential for intrauterine infection.
A: If the patient’s condition is stable enough for the patient to be transported to the radiology suite and preservation of fertility is desired, uterine artery embolization (often as a supplement to intrauterine balloon tamponade) can be considered. The uterine artery embolization procedure involves injection of gelatin or polyvinyl alcohol particles into the uterine artery or the anterior division of the internal iliac arteries through the femoral arteries with the use of the Seldinger technique under fluoroscopic and ultrasonographic guidance. Success rates in the control of postpartum hemorrhage range from 75 to 100%, and pregnancy after uterine artery embolization has been reported in 43 to 48% of women.